Illinois General Assembly - Full Text of HB2814
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Full Text of HB2814  101st General Assembly




State of Illinois
2019 and 2020


Introduced , by Rep. Camille Y. Lilly


305 ILCS 5/5-30.1
305 ILCS 5/5-30.11 new

    Amends the Medical Assistance Article of the Illinois Public Aid Code. Requires the Department of Healthcare and Family Services to require managed care organizations (MCOs) to ensure: (1) that any provider under contract with an MCO on the date of service shall be paid for any medically necessary service rendered to any of the MCO's enrollees, regardless of inclusion on the MCO's published and publicly available roster of available providers; (2) that all contracted providers are listed on an updated roster within 7 days of entering into a contract with the MCO; and (3) that the roster under item (2) is readily accessible by all medical assistance enrollees for purposes of selecting an approved healthcare provider. Requires the Department to require MCOs to expedite payments to providers based on specified criteria (rather than providing that the Department may establish a process for MCOs to expedite payments to providers based on criteria established by the Department). Contains provisions concerning discharge notifications and facility placements and other matters. Effective immediately.

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HB2814LRB101 09321 KTG 54416 b

1    AN ACT concerning public aid.
2    Be it enacted by the People of the State of Illinois,
3represented in the General Assembly:
4    Section 5. The Illinois Public Aid Code is amended by
5changing Section 5-30.1 and by adding Section 5-30.11 as
7    (305 ILCS 5/5-30.1)
8    Sec. 5-30.1. Managed care protections.
9    (a) As used in this Section:
10    "Managed care organization" or "MCO" means any entity which
11contracts with the Department to provide services where payment
12for medical services is made on a capitated basis.
13    "Emergency services" include:
14        (1) emergency services, as defined by Section 10 of the
15    Managed Care Reform and Patient Rights Act;
16        (2) emergency medical screening examinations, as
17    defined by Section 10 of the Managed Care Reform and
18    Patient Rights Act;
19        (3) post-stabilization medical services, as defined by
20    Section 10 of the Managed Care Reform and Patient Rights
21    Act; and
22        (4) emergency medical conditions, as defined by
23    Section 10 of the Managed Care Reform and Patient Rights



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1    Act.
2    (b) As provided by Section 5-16.12, managed care
3organizations are subject to the provisions of the Managed Care
4Reform and Patient Rights Act.
5    (c) An MCO shall pay any provider of emergency services
6that does not have in effect a contract with the contracted
7Medicaid MCO. The default rate of reimbursement shall be the
8rate paid under Illinois Medicaid fee-for-service program
9methodology, including all policy adjusters, including but not
10limited to Medicaid High Volume Adjustments, Medicaid
11Percentage Adjustments, Outpatient High Volume Adjustments,
12and all outlier add-on adjustments to the extent such
13adjustments are incorporated in the development of the
14applicable MCO capitated rates.
15    (d) An MCO shall pay for all post-stabilization services as
16a covered service in any of the following situations:
17        (1) the MCO authorized such services;
18        (2) such services were administered to maintain the
19    enrollee's stabilized condition within one hour after a
20    request to the MCO for authorization of further
21    post-stabilization services;
22        (3) the MCO did not respond to a request to authorize
23    such services within one hour;
24        (4) the MCO could not be contacted; or
25        (5) the MCO and the treating provider, if the treating
26    provider is a non-affiliated provider, could not reach an



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1    agreement concerning the enrollee's care and an affiliated
2    provider was unavailable for a consultation, in which case
3    the MCO must pay for such services rendered by the treating
4    non-affiliated provider until an affiliated provider was
5    reached and either concurred with the treating
6    non-affiliated provider's plan of care or assumed
7    responsibility for the enrollee's care. Such payment shall
8    be made at the default rate of reimbursement paid under
9    Illinois Medicaid fee-for-service program methodology,
10    including all policy adjusters, including but not limited
11    to Medicaid High Volume Adjustments, Medicaid Percentage
12    Adjustments, Outpatient High Volume Adjustments and all
13    outlier add-on adjustments to the extent that such
14    adjustments are incorporated in the development of the
15    applicable MCO capitated rates.
16    (e) The following requirements apply to MCOs in determining
17payment for all emergency services:
18        (1) MCOs shall not impose any requirements for prior
19    approval of emergency services.
20        (2) The MCO shall cover emergency services provided to
21    enrollees who are temporarily away from their residence and
22    outside the contracting area to the extent that the
23    enrollees would be entitled to the emergency services if
24    they still were within the contracting area.
25        (3) The MCO shall have no obligation to cover medical
26    services provided on an emergency basis that are not



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1    covered services under the contract.
2        (4) The MCO shall not condition coverage for emergency
3    services on the treating provider notifying the MCO of the
4    enrollee's screening and treatment within 10 days after
5    presentation for emergency services.
6        (5) The determination of the attending emergency
7    physician, or the provider actually treating the enrollee,
8    of whether an enrollee is sufficiently stabilized for
9    discharge or transfer to another facility, shall be binding
10    on the MCO. The MCO shall cover emergency services for all
11    enrollees whether the emergency services are provided by an
12    affiliated or non-affiliated provider.
13        (6) The MCO's financial responsibility for
14    post-stabilization care services it has not pre-approved
15    ends when:
16            (A) a plan physician with privileges at the
17        treating hospital assumes responsibility for the
18        enrollee's care;
19            (B) a plan physician assumes responsibility for
20        the enrollee's care through transfer;
21            (C) a contracting entity representative and the
22        treating physician reach an agreement concerning the
23        enrollee's care; or
24            (D) the enrollee is discharged.
25    (f) Network adequacy and transparency.
26        (1) The Department shall:



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1            (A) ensure that an adequate provider network is in
2        place, taking into consideration health professional
3        shortage areas and medically underserved areas;
4            (B) publicly release an explanation of its process
5        for analyzing network adequacy;
6            (C) periodically ensure that an MCO continues to
7        have an adequate network in place; and
8            (D) require MCOs, including Medicaid Managed Care
9        Entities as defined in Section 5-30.2, to meet provider
10        directory requirements under Section 5-30.3; and .
11            (E) require MCOs to: (i) ensure that any provider
12        under contract with an MCO on the date of service is
13        paid for any medically necessary service rendered to
14        any of the MCO's enrollees, regardless of inclusion on
15        the MCO's published and publicly available roster of
16        available providers; and (ii) ensure that all
17        contracted providers are listed on an updated roster
18        within 7 days of entering into a contract with the MCO
19        and that such roster is readily accessible to all
20        medical assistance enrollees for purposes of selecting
21        an approved healthcare provider.
22        (2) Each MCO shall confirm its receipt of information
23    submitted specific to physician or dentist additions or
24    physician or dentist deletions from the MCO's provider
25    network within 3 days after receiving all required
26    information from contracted physicians or dentists, and



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1    electronic physician and dental directories must be
2    updated consistent with current rules as published by the
3    Centers for Medicare and Medicaid Services or its successor
4    agency.
5    (g) Timely payment of claims.
6        (1) The MCO shall pay a claim within 30 days of
7    receiving a claim that contains all the essential
8    information needed to adjudicate the claim.
9        (2) The MCO shall notify the billing party of its
10    inability to adjudicate a claim within 30 days of receiving
11    that claim.
12        (3) The MCO shall pay a penalty that is at least equal
13    to the penalty imposed under the Illinois Insurance Code
14    for any claims not timely paid.
15        (4) The Department shall require MCOs to expedite
16    payments to providers based on criteria that include, but
17    are not limited to: may establish a process for MCOs to
18    expedite payments to providers based on criteria
19    established by the Department.
20            (A) At a minimum, each MCO shall ensure that
21        providers identified on the Department's expedited
22        provider list, determined in accordance with 89 Ill.
23        Adm. Code 140.71(b), are paid by the MCO on a schedule
24        at least as frequently as the providers are paid under
25        the Department's fee-for-service expedited provider
26        schedule.



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1            (B) Compliance with the expedited provider
2        requirement may be satisfied by an MCO through the use
3        of a Periodic Interim Payment (PIP) program that has
4        been mutually agreed to and documented between the MCO
5        and the provider, if the PIP program ensures that any
6        expedited provider receives regular and periodic
7        payments based on prior period payment experience from
8        that MCO. Total payments under the PIP program may be
9        reconciled against future PIP payments on a schedule
10        mutually agreed to between the MCO and the provider.
11    (g-5) Recognizing that the rapid transformation of the
12Illinois Medicaid program may have unintended operational
13challenges for both payers and providers:
14        (1) in no instance shall a medically necessary covered
15    service rendered in good faith, based upon eligibility
16    information documented by the provider, be denied coverage
17    or diminished in payment amount if the eligibility or
18    coverage information available at the time the service was
19    rendered is later found to be inaccurate; and
20        (2) the Department shall, by December 31, 2016, adopt
21    rules establishing policies that shall be included in the
22    Medicaid managed care policy and procedures manual
23    addressing payment resolutions in situations in which a
24    provider renders services based upon information obtained
25    after verifying a patient's eligibility and coverage plan
26    through either the Department's current enrollment system



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1    or a system operated by the coverage plan identified by the
2    patient presenting for services:
3            (A) such medically necessary covered services
4        shall be considered rendered in good faith;
5            (B) such policies and procedures shall be
6        developed in consultation with industry
7        representatives of the Medicaid managed care health
8        plans and representatives of provider associations
9        representing the majority of providers within the
10        identified provider industry; and
11            (C) such rules shall be published for a review and
12        comment period of no less than 30 days on the
13        Department's website with final rules remaining
14        available on the Department's website.
15        (3) The rules on payment resolutions shall include, but
16    not be limited to:
17            (A) the extension of the timely filing period;
18            (B) retroactive prior authorizations; and
19            (C) guaranteed minimum payment rate of no less than
20        the current, as of the date of service, fee-for-service
21        rate, plus all applicable add-ons, when the resulting
22        service relationship is out of network.
23        (4) The rules shall be applicable for both MCO coverage
24    and fee-for-service coverage.
25    (g-6) MCO Performance Metrics Report.
26        (1) The Department shall publish, on at least a



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1    quarterly basis, each MCO's operational performance,
2    including, but not limited to, the following categories of
3    metrics:
4            (A) claims payment, including timeliness and
5        accuracy;
6            (B) prior authorizations;
7            (C) grievance and appeals;
8            (D) utilization statistics;
9            (E) provider disputes;
10            (F) provider credentialing; and
11            (G) member and provider customer service.
12        (2) The Department shall ensure that the metrics report
13    is accessible to providers online by January 1, 2017.
14        (3) The metrics shall be developed in consultation with
15    industry representatives of the Medicaid managed care
16    health plans and representatives of associations
17    representing the majority of providers within the
18    identified industry.
19        (4) Metrics shall be defined and incorporated into the
20    applicable Managed Care Policy Manual issued by the
21    Department.
22    (g-7) MCO claims processing and performance analysis. In
23order to monitor MCO payments to hospital providers, pursuant
24to this amendatory Act of the 100th General Assembly, the
25Department shall post an analysis of MCO claims processing and
26payment performance on its website every 6 months. Such



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1analysis shall include a review and evaluation of a
2representative sample of hospital claims that are rejected and
3denied for clean and unclean claims and the top 5 reasons for
4such actions and timeliness of claims adjudication, which
5identifies the percentage of claims adjudicated within 30, 60,
690, and over 90 days, and the dollar amounts associated with
7those claims. The Department shall post the contracted claims
8report required by HealthChoice Illinois on its website every 3
10    (g-8) Notwithstanding any other provision of law, if the
11Department or an MCO requires submission of a claim for payment
12in a non-electronic format, a provider shall always be afforded
13a period of no less than 90 business days, as a correction
14period, following any notification of rejection by either the
15Department or the MCO to correct errors or omissions in the
16original submission.
17    Under no circumstances, either by an MCO or under the
18State's fee-for-service system, shall a provider be denied
19payment for failure to comply with any timely claims submission
20requirements under this Code or under any existing contract,
21unless the non-electronic format claim submission occurs after
22the initial 180 days following the latest date of service on
23the claim, or after the 90 business days correction period
24following notification to the provider of rejection or denial
25of payment.
26    (h) The Department shall not expand mandatory MCO



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1enrollment into new counties beyond those counties already
2designated by the Department as of June 1, 2014 for the
3individuals whose eligibility for medical assistance is not the
4seniors or people with disabilities population until the
5Department provides an opportunity for accountable care
6entities and MCOs to participate in such newly designated
8    (i) The requirements of this Section apply to contracts
9with accountable care entities and MCOs entered into, amended,
10or renewed after June 16, 2014 (the effective date of Public
11Act 98-651).
12    (j) The requirements of this Section added by this
13amendatory Act of the 101st General Assembly shall apply to
14services provided on or after the first day of the month that
15begins 60 days after the effective date of this amendatory Act
16of the 101st General Assembly.
17(Source: P.A. 99-725, eff. 8-5-16; 99-751, eff. 8-5-16;
18100-201, eff. 8-18-17; 100-580, eff. 3-12-18; 100-587, eff.
20    (305 ILCS 5/5-30.11 new)
21    Sec. 5-30.11. Discharge notification and facility
22placement of individuals; managed care. Whenever a hospital
23provides notice to a managed care organization (MCO) that an
24individual covered under the State's medical assistance
25program has received a discharge order from the attending



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1physician and is ready for discharge from an inpatient hospital
2stay to another level of care, the MCO shall secure the
3individual's placement in or transfer to another facility
4within 24 hours of receiving the hospital's notification, or
5shall pay the hospital a daily rate equal to the hospital's
6daily rate associated with the stay ending, including all
7applicable add-on adjustment payments.
8    Section 99. Effective date. This Act takes effect upon
9becoming law.